Overview of Diabetes Mellitus

Dr F Dunne
Dept of Medicine

Layout

Definition
Diagnosis
Classification
Symptoms
Annual Assessment
Treatment options

Metabolic

complications
Macrovascular
complications
Microvascular
complications

Definition
A syndrome caused by a decrease or total
lack of insulin or diminished effectiveness
of circulating insulin (insulin resistance)
Characterised by hyperglycaemia

Insulin
Enhances peripheral glucose uptake
Inhibits breakdown of liver glycogen
Enhances storage of glucose as glycogen
Increases protein synthesis
Increases triglyceride storage

Diagnosis
Fasting blood glucose > 7mmol/l
Random blood glucose >11.1mmol/l
75g OGTT

75g OGTT
Diabetic:
IGT :
IFG:

FBG>7; 2h >11.1 mmol/l

FBG <7; 2h 7.8-11.1 mmol/l
FBG 6.1-6.9 mmol/l

Classification
Type 1 diabetes
Type 2 diabetes
Secondary diabetes

Type 1 diabetes;Type 2 diabetes

Juvenille
Abrupt onset
Family history
Autoimmune
Ketones
Total insulin def,
Islet cell AB pos
HLA DR3 DR4
Insulin dependent

Older age
Slow onset
Family history
Not autoimmune
No ketones
Partial Insulin
def/Resistance
Insulin requiring
Diet/OHA

Secondary Diabetes

Steroids
Thiazide Diuretics
Drugs for HIV
Pancreatectomy

Acute pancreatitis
Chronic Pancreatitis
Haemachromatosis
Cystic Fibrosis
Cushings Disease
Acromegaly
MODY
DIDMOAD

Symptoms

Polyuria
Polydypsia
Weight loss
Lethargy
Tiredness
Blurred Vision
Boils/abscesses
Pruritus Vulvae

DKA
Retinopathy
Nephropathy
Neuropathy
Foot ulcers/gangrene
Angina/MI/CVA

Annual Assessment

Osmotic symptoms
Hypoglycaemia
Injection sites
Treatment
Diabetes nurse
specialist
Dietitian

Blood pressure
VAs Fundoscopy
Pulses/CFT
Neurology of Legs
Urinalysis
HbA1C
Lipids
Renal function

Treatment
Relief of osmotic symptoms
Avoid complications
Choice of treatments dependent on type,
age, family support etc.

Treatments of Glucose
Diet
Metformin
Sulphonylureas
Acarbose
Thiazolidinediones
Netaglinide/Repag.

Rapid acting Insulin

Long acting Insulin
Mixed Insulins
Short acting
analogues
Long acting
analogues

Other treatments
Anti-hypertensives
Statins/fibrates
Aspirin
ACE inhibitors
ARBs

Treat to Target
HbA1C < 7%
BP < 140/80
Cholesterol <5 mmol/l
HDL-C >1mmol/l
LDL-C < 2mmol/l
Triglycerides <1.5mmol/l

Hypoglycaemia <2.5mmol/l
Autonomic
Neuroglycopenic
LOC
Cerebral Oedema

Too much insulin

Food omission
Sulphonylureas
Renal impairement

Treatment
Food
Dextrose tablets
Hypostop
Glucose infusion
Glucagon

DKA Serious/Life threatening

Infection
Omits insulin
Dehydration
Ketotic
Hyperventilating
Hypotensive
Tachycardia
Coma

Glucose/ketones/

acidotic on ABG
IV Fluids
Insulin
Potassium
Antibiotics

HONK

Type 2
Unwell for days
Not acidotic
No ketones
Very high glucose
Risk of clotting

Fluids
Insulin
Potassium
Heparin

Neuropathy
Peripheral Neurop
Femoral Amyotrophy
Mononeuritis
multiplex

Autonomic

Neuropathy
Postural hypotension
Diarrhoea
Impotence
Atonic bladder
Sweating
Loss of hypo. awarenes

Vascular Disease
PVD
CVD
CAD

Diabetes
Hypertension
Proteinuria
Lipids
Cigarettes
Obesity

PVD
Intermittent

Claudication
Cold Legs
Pulseless Leg
Foot Ulcers
Gangrene

Doppler Studies
Duplex Scanning
Angiography
Angioplasty
Treat risk factors

CVD
TIAs
CVAs
Dementia

CT scan
Carotid Dopplers
Treat risk factors
Carotid bypass
surgery

CAD

Angina
MI
Silent infarct
CCF

ECG
Cardiac enzymes
Troponin I
Exercise stress test
Echocardiography
Angiography
Angioplasty/CABG

Diabetic Foot

Neuropathy
PVD
Charcot Arthropathy
Ulceration

MRI
Angiography

Retinopathy

Background DR
Pre-proliferative DR
Proliferative DR
Maculopathy

Fluroscein

angiography
Laser
Blood Pressure
Lipids
Glucose

Nephropathy
Diabetic

glomerulosclerosis
Microalbuminuria
<300mg/l
Proteinuria >300mg/l
Nephrotic >3g/l
Abnormal creatinine

Glycaemic control
BP control
CAPD
Transplantation

Screening

BMI>30
Age >50
Ethnic minorities
Family history
GDM

Urinalysis
FBG
Random glucose
OGTT
Cost/benefit analysis

Diabetes is preventable by life style

modification
Da Quing (Chinnese)31-46% reduction
Finnish (Europeans)58% reduction
DPP (North Americans) 58% reduction
STOP NIDDM Trial Acarbose
Lancet 2002;359: 2072-2077.
JAMA 2003;290: 486-494
TRIPOD Study
Pioglitazone

Literature
DCCT Trial(Type1)

Diabetes 1996;45: 12891298 NEJM 1993;329;977

UKPDS study (Type 2)
Lancet 1998;352:837-853
DIGAMI (CCU)
BMJ 1997;314:1512-1515
Lancet 2002:259;
Lancet 2000; 355: 733777
ICU patients NEJM
2001;345:1359-1367

WOSCOPS; 4S; ASCOT

Lancet 2003;361;11491158 (Statin)

HOPE (ACE-I) NEJM
2000;342:145-153
ALL-HAT (ACE-I) JAMA
2002;288:2981-2997
LIFE SCOPE (ARB)
CARDS Study (Lancet
August 2004)
DIGAMI 2 study (in
press).